2013年 · 第36卷第10期

With the extension of the average life expectancy of Chinese people and the aging of inpatients, it is not surprising that the average age of inpatients in respiratory department exceeds 70 years old, and some hospitals may even exceed 80 years old. How we should deal with super-elderly patients and whether some risky medical operations should be carried out often confuse us. A special case is cited for readers' reference.

The most common adverse reaction of anti-tuberculosis drugs is drug-induced liver injury (DILI). The incidence of DILI caused by anti-tuberculosis drugs varies greatly in different countries, ranging from 2% to 30%, which may be related to factors such as ethnicity, socioeconomic status, geographical location, research methods, diagnostic criteria of DILI and local viral hepatitis prevalence. Generally speaking, the incidence of DILI caused by anti-tuberculosis drugs in China is high, ranging from 8% to 30%, which is also the most common cause of DILI^[1]； Incidence of DILI due to anti-tuberculosis drugs in other countries and regions: United States<1%, 4% in the UK, 3.3% in Barcelona and 0.8% to 18% in Turkey. The incidence of DILI caused by anti-tuberculosis drugs was higher in isoniazid, rifampicin, pyrazinamide, rifabutin, rifampentine, prothioisonicotinamide and sodium p-aminosalicylate, while the incidence of DILI caused by anti-tuberculosis drugs was lower in fluoroquinolones, ethambutol, clofazimin, clarithromycin and amoxicillin/clavulanate potassium. DILI usually occurred within 3 months after the start of anti-tuberculosis treatment.

At present, drug-induced liver injury (DILI) is attracting more and more attention. DILI accounts for 30% to 40% of the causes of acute liver failure in European and American countries. It is estimated that the global incidence of DILI can be as high as 13.9 per 100,000^[1]。 DILI has become a bottleneck in drug development^[2]。 The number of patients hospitalized due to acute DILI in China has increased year by year in the past five years^[3]。

The adverse reactions of anti-tuberculosis drugs mainly include drug-induced liver injury (DILI), peripheral neuritis, gastrointestinal reactions and skin rash, among which DILI is the most common and the most serious, which is the root cause of treatment interruption, change of regimen, decrease of efficacy and drug resistance. Although the general prognosis of DILI is good, and some patients only have asymptomatic aminotransferase elevation, severe DILI can cause acute liver failure, and the mortality rate is about 0.4% to 1.5%, accounting for 5.7% of the mortality rate of liver failure^[1]。 The incidence of DILI caused by anti-tuberculosis drugs is about 2% ~28%^[2,3,4]Due to different ethnicity, geographical environment and diagnostic criteria, the actual incidence rate is difficult to determine. Isoniazid, rifampicin and pyrazinamide have strong hepatotoxicity, and their combined use can increase the risk of liver injury^[5]。

A variety of anti-tuberculosis drugs can induce adverse reactions to drug-induced liver injury (DILI)^[1,2,3,4]Its incidence varies greatly in different periods, countries and literature reports, ranging from 2.5% to 35%^[5,6,7]。 The severity of patients with DILI varies, with transient elevation of aminotransferase in mild cases and liver failure in severe cases^[8]And the mortality rate is high. If a patient has to discontinue anti-tuberculosis therapy because of DILI, the consequences are no less serious than DILI itself, so prevention and treatment of DILI is related to the success of anti-tuberculosis therapy and the reduction of drug resistance. The author explains how to deal with the problem of DILI induced by anti-tuberculosis drug treatment as follows.

In the course of anti-tuberculosis treatment of tuberculosis, various degrees of adverse drug reactions may occur. Among them, drug-induced liver injury (DILI) caused by anti-tuberculosis drugs is the most common and harmful. It is also one of the common types of DILI in China. Mild cases are manifested as transient transaminase increases, and severe cases can cause liver failure or even life-threatening. Therefore, some patients have to stop anti-tuberculosis treatment, which affects the treatment effect of tuberculosis. Clinicians should attach great importance to this problem. At present, there is still a lack of unified diagnostic criteria and treatment guidelines for DILI caused by anti-tuberculosis drugs at home and abroad. In order to improve the understanding and treatment level of DILI caused by anti-tuberculosis drugs among clinicians, this recommendation has been formed by holding many seminars and inviting experts from multiple disciplines such as tuberculosis, liver disease and pharmacology to conduct repeated discussions and revisions.

Both the first-and second-line drugs for the treatment of tuberculosis can cause adverse reactions, among which drug-induced liver injury (DILI) is the most influential and the incidence is high^[1,2]DILI is critical to patients' compliance and ensuring the efficacy of tuberculosis treatment, so it has always been the focus of attention of tuberculosis clinicians.

Chronic liver diseases such as cirrhosis and chronic hepatitis are common diseases in developing countries, and active tuberculosis patients with liver disease are not uncommon. There is still a lack of consensus on how to treat such patients with antituberculosis drugs, and no country has developed relevant guidelines or consensus. The author summarizes the research progress in this area to provide reference for the treatment of patients with liver disease complicated with tuberculosis.

Although there are anti-tuberculosis drugs in the treatment of tuberculosis, with the increasing drug resistance rate and the emergence of multi-drug resistant tuberculosis (MDR-TB) and extensively drug resistant tuberculosis, new methods are needed to prevent and treat this disease. By regulating the immune system of tuberculosis patients and improving the anti-MTB ability of the body, it is expected to provide new ideas for anti-tuberculosis treatment. In recent years, the association between tuberculosis susceptibility and vitamin D deficiency^[1]and 1,25-dihydroxyvitamin D₃[1, 25- (OH)₂-D₃The immunomodulatory effect of] has attracted more and more attention, and the author reviews its research progress as follows.

pulmonary alvevlar microlithiasis (PAM) is a rare clinical disease characterized by diffuse distribution of calcium and phosphate-containing microlithiasis in the alveoli of both lungs. Its specific cause and mechanism are unknown. The disease was first reported by Malpighi in 1686, imaging was described by Harbitz in 1918, and named by Puhr in 1933^[1]。 So far, about 600 cases of PAM have been reported worldwide.

pulmonary thromboembolism (PTE) is a disease caused by thrombus from the venous system or right heart blocking the pulmonary artery or its branches. The main clinical and pathophysiological features are pulmonary circulation and respiratory dysfunction. PTE is a disease with high morbidity, high mortality and high disability rate. In recent years, with the deepening of clinicians' understanding and attention to PTE, the diagnosis rate of this disease is increasing year by year. thrombosis of PTE mainly comes from deep venous thrombosis (DVT), which is common in lower limb veins and pelvic veins. DVT and PTE are essentially the manifestations of the same disease process at different sites and stages, collectively called venous thromboembolism (VTE).

Chronic obstructive pulmonary disease (COPD) and obstructive sleep apnea-hyponea syndrome (OSAHS) are common diseases in China, with incidence rates of about 8.3% and 4.0% in adults, respectively^[1,2]The incidence and mortality of COPD rank fourth in China. When suffering from COPD and OSAHS at the same time, it is called overlap syndrome (OS), and the incidence is higher in the elderly. The pathophysiological changes of OS patients are complex, and they are more prone to respiratory failure, pulmonary hypertension, cardiovascular and cerebrovascular events, etc. In this study, two groups of elderly patients with OS with respiratory failure who were treated with bi-PAP and not treated with bi-PAP were followed up for 5 years. To investigate the effects of bi-PAP on respiratory failure, nocturnal hypoxia, and pulmonary function FEV in elderly patients with OS with respiratory failure₁Impact of % of the projected value, number of hospitalizations for acute exacerbations per year and survival.

The patient was a 44-year-old male, farmer, Han nationality. He was admitted to hospital in September 2010 due to intermittent chest tightness, chest pain and cough for more than 2 years. In January 2010, the patient went to a local hospital for nearly 2 years due to intermittent chest tightness, chest pain and cough. Chest CT showed inflammation of both lungs (mainly interstitial, details unknown); Pulmonary function showed: FEV₁% of estimates is 74.5%, FEV₁/FVC was 89.04%, TLC was 53.7%, D_LCO accounted for 37.1% of the projected value; Pathological report of thoracoscopic biopsy of the lower lobe of the left lung: inflammatory lesions of the left lung with organization and alveolar epithelial hyperplasia, considered as interstitial lung disease. After diagnosis, oral prednisone was given and tapered as follows: 30 mg once/d, changed to 25 mg once/d after 1 month, changed to 15 mg once/d after 1 month, changed to 10 mg once/d after 1 month, changed to 5 mg once/d after 1 month, changed to 5 mg once every other day after 1 month, and discontinued after 1 month. After treatment, the symptoms of chest tightness and cough were relieved, but there was still wheezing when I went upstairs, and there was no obvious improvement in chest CT after reexamination. He was transferred to our hospital for treatment in September 2010. Deny a similar medical history among parents in close marriage or siblings. Past health, no history of special medication. Physical examination: The color of skin and sclera was normal, and the inspiratory phase of both lower lungs burst. Peripheral blood platelet count was normal (302×10¹²/L); Platelet aggregation test was normal (10 μ mol/L adenosine diphosphate 78%, normal reference value: 71%-88%). Pulmonary function suggests restrictive ventilatory dysfunction with reduced diffusion function (FEV₁% of estimated value was 67.8%, FEV₁/FVC in % of predicted value 96.64%, TLC in % of predicted value 66.1%, dispersion rate 0.81). Chest CT showed cord-like shadows around both lungs, multiple small cystic changes under the pleura, some of which were honeycomb-shaped (Figure 1，Figure 2), surrounded by small patches and nodular shadow foci; Pulmonary bullae were formed next to the mediastinum in the anterior segment of the left upper lung; Bilateral thickening of pleural adhesions.

An 82-year-old female was admitted to the First Hospital of Peking University on May 5, 2011 due to "intermittent dry cough for 10 years, aggravated with fever for 10 days". The patient developed mild dry cough 10 years ago, without symptoms such as fever, chest tightness and chest pain, and X-ray chest radiographs showed interstitial changes in both lower lungs (Figure 1)； CT of the chest showed subpleural grid and ground glass shadows of both lungs, and the diagnosis of "idiopathic pulmonary fibrosis" in the outside hospital was not treated; Subsequently, he coughed intermittently, and annual physical examination showed no obvious progression of lung lesions; One month before admission, fatigue and loss of appetite began, and 10 days ago, cough worsened without trigger, accompanied by fever, muscle soreness, body temperature as high as 38.8 ℃, and no chills, rash, oral ulcer and joint pain. Peripheral blood leukocytes were 16×10 in other hospitals⁹/L, neutrophils were 0.86, ESR was 84 mm/1 h, CRP was 74.7 mg/L, X-ray chest radiographs showed interstitial-like lesions in both lower lungs, and suspicious nodules in the left lower lung (Figure 2)。 The other hospital gave "ceftazidime" intravenous drip for 5 days, but the symptoms did not improve, so he was admitted to our hospital for further diagnosis and treatment. Has had hypertension for 30 years; Smoking 10 packs per year, has quit smoking for 30 years. Physical examination: body temperature 37.9 ℃, pulse 98 beats/min, breathing 25 beats/min, blood pressure 110/60 mm Hg (1 mm Hg =0.133 kPa). Acute disease, physical weakness. Superficial lymph nodes were unpalpable and enlarged. The neck is soft, no resistance, and the thyroid is not large. The breathing sounds of both lungs were thick, and inspiratory bursting sounds and wet rales could be heard in the right middle and lower lungs and the left lower lungs. Heart rhythm, no murmur. The abdomen is flat and soft, without tenderness. Mild concave edema of both lower limbs. Auxiliary examination: Albumin was 25 g/L, serum creatinine was 69 μ mol/L, and urea nitrogen was 4 mmol/L. Admission diagnosis: fever, interstitial pneumonia cause to be investigated, hypoalbuminemia.

invasive pulmonary aspergillosis (IPA), 1953 by Rankin^[1]First, it was reported that the manifestations include cough, expectoration, fever, pleurisy-like chest pain and hemoptysis, such as shortness of breath and dyspnea, and even respiratory failure when the lesions are extensive. Aspergillus invasion of blood vessels can be manifested as hemoptysis, and massive hemoptysis asphyxia can be life-threatening^[2]However, there are few reports of death from asphyxia caused by large airway obstruction caused by non-massive hemoptysis. Now, a death case of main bronchial asphyxia caused by sudden necrotic substance obstruction by IPA admitted to our hospital is reported, so as to improve clinicians' understanding of the complications of pulmonary aspergillosis.

In recent years, with the widespread application of immunosuppressants, broad-spectrum antibiotics, and the increase of patients with immunodeficiency diseases such as tuberculosis and AIDS, the clinical reports of invasive pulmonary fungal infection have gradually increased^[1,2,3]However, it is rare for invasive pulmonary fungal infection to be misdiagnosed as lung cancer and tuberculosis at the same time. In order to improve the understanding of this disease among medical workers in imaging department, tuberculosis department and respiratory department, and avoid the occurrence of misdiagnosis and mistreatment, the diagnosis and treatment of a case of pulmonary Aspergillus infection misdiagnosed as lung cancer and pulmonary tuberculosis was retrospectively analyzed, and the relevant literature was reviewed.

Lung transplantation is the only effective treatment for end-stage lung disease, and airway complications are one of the main causes of surgical failure and common postoperative complications. With the continuous improvement of patient selection, organ protection, surgical technique, immunosuppressive therapy and postoperative monitoring, the success rate of surgery has been greatly improved, but postoperative airway complications are still more common. At present, there are no large sample observation reports on the diagnosis and treatment of airway complications after lung transplantation in China. Now, the clinical and follow-up data of 42 patients who underwent lung transplantation in the First Affiliated Hospital of Guangzhou Medical College from January 2003 to March 2012 are retrospectively analyzed, and the occurrence of airway complications after lung transplantation and the value of bronchoscopy in treating airway complications are analyzed, so as to provide reference for clinical diagnosis and treatment.

The Golden Autumn October ushered in the Double Ninth Festival, which is a festival for the elderly and closely related to each of us. With the acceleration of aging in China, how do medical units and medical workers cope with the social problems and pressures brought by aging, this serious problem is placed in front of medical staff. In the column of "Editor-in-Chief's Essays" in this issue, editor-in-chief Liu Youning wrote an article "Enlightenment from the Medical Process of a Centenarian", telling the story of a centenarian who suffered from femoral neck fracture and acute respiratory failure and aspiration pneumonia, and had undergone mechanical ventilation. In this case, the risk can be imagined because his family strongly demanded femoral head replacement. Although the operation itself was successful, due to the prolonged mechanical ventilation, the patient was complicated with ventilator-associated pneumonia and sepsis caused by multidrug-resistant bacteria, and his life was once hanging by a thread. It is not uncommon in clinical practice that doctors are reluctant to do something like this, but the consequence of patients not having surgery is long-term bed rest, which greatly reduces their quality of life, and the consequent comorbidities will also shorten their life span. Therefore, while clinicians should refer to authoritative guidelines when weighing the diagnosis and treatment plan of elderly patients, it is even more important whether they can make appropriate and person-to-person targeted decisions for individual patients.